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Ketogenic diet - Coggle Diagram
Ketogenic diet
RCT evidence for use of KD in children epilepsy
Children classical and MCT ketogenic diet RCT (Neal et al 2008): 38% achieved 50% reduction in seizures compared to control diet (6%). 7% received 90% reduction whereas control diet had 0% reduction
Fewer trial with adults. Meta-analysis 2015.
2020 Cochrane review - 55% achieved seizure freedom and 88% seizure reduction from classical KD. Modified atkins diet for 3 months, 60% seizure reduction and 25% seizure freedom.
Quality of evidence criticised as low sample sizes
2018 International consensus- KDT can effectively treat individuals: infant to adults
Epilepsy syndromes with response to KDT consistently better than average.
UK guidance on KDT: Certain childhood-onset epilepsy syndromes an drug resistant epilepsy if other treatment options have been unsuccessful
Ketogenic diet in treatment of epilepsy
Around 25-30% of cases are not treatable with drugs so require alternative treatments
International recommendations for management of adults treated with ketogenic diet 2021
How does it work? Multiple pathways
Direct
ketones as additional fuel, reduced/stable blood glucose levels, lower insulin levels
Indirect
enhanced mitochondria function, alters neurotransmitter metabolism, influences cellular redox status, modulates gene expression (epigenetic), regulation of inflammation, alterations in gut microbiome
Alternative fuel provision
KD diet produces an overall fuel increase in cerebral energy reserve and energy charge
'Novel fuel' approaches under investigation- Medium chain triglycerides and ketone esters
Alterations in gut microbiome- shown people with epilepsy have different microbiota in gut. Studies show when mice changed to keto diet, bacteria profile change and new microbiome can be transplanted and produce ketogenic effect in epileptic mice
possibly different mechanisms in different disorders
What is it? Mimics metabolic effects of fasting. Low CHO drives change of fueling.
standard western around 225g CHO, Keto 22g CHO
Primary foods fats and protein
Myths and misunderstandings
Does not always cause weight loss.
Is nutritional ketosis same as ketoacidosis? No- nutritional ketosis is controlled, insulin regulated process and blood ketones stay within 1-7 mmol/L range, gluocse within normal range and pH in normal range. In ketoacidosis, uncontrolled and lack of insulin where blood glucose above normal range and ketones >10mmol/L..
Medical considerations- inborn errors of fatty acid metabolism can impact suitability for treatment (usually known as have issues if fasted for period time).
Practical considertions- able to do 3 month trial, cook from scratch, able to record and feedback ketone, gluocse, weight ht etc to team
Consideration- biochem? Carnintine profile? fasting lipid etc
What does keto diet look like?
enterally or orally
Diet therapy options
Classical, medium chain triglyceride KD, modified atkins diet, low glycaemic index treatment
Modified ketogenic diet: 20-30g daily, need to meet fat requirements (10g choices) , monitor weight weekly to avoid weight loss/ gain, normal protein levels, drinks fluids, (150g fat in 1800kcal diet, 90g protein, 22g CHO)
Classical ketogenic diet- energy delivered same ketogenic ratio across meals (2:1 ratio profile to deliver 1800kcals, 164g fat, 82g protein and cho e.g. 22g CHO with 60g protein)
ratio in diet of fat to protein+ CHO (high ratio 4:1 can cause risk to adults as protein intake may be inadequate)
KD has other benefits in epilepsy: improved quality of life, mental conception clearer, alertness, memory and sleep improved. Come back from seizures fast.
Negative effects: constipation (can be alleviated and planned for), lethargy in early stages (particularly if introducing diet regime rapidly), unplanned weight loss/gain, raised cholesterol (adjust fat composition, usually raised HDL), renal calculi, some can have increased seizures.
Lipid concerns
Can increase lipid profile but benefits > harm (improved QOL, reduced seizures). Can have HDL and LDL increases. Assess fat sources and target guidance e.g. reduce SFA and increased PUFA and MUFA, increased nuts and seeds, fatty fish 2/3 times weekly, fish oils supplements, add L-carnitine. When starting diet, can eat any fat they like and adjust over time.
Current research into use of keto diet for other areas- oncology (brain tumours), Alzheimer's, Parkinson's. Increase in research over last decade
Gluocse transporter disorderr requiring KD start